Classification of SARS-CoV-2 Pediatric Hospitalizations: Delta vs Omicron Variant.

OBJECTIVES: To classify COVID-19 pediatric hospitalizations based on reason for admission ("for COVID" or "with COVID") and to compare disease severity and age between the delta and omicron variant predominant time frames. METHODS: This was a retrospective study in patients aged ≤18 years who were hospitalized at a large, tertiary care pediatric hospital for COVID-19 from July 2021 to February 2022. Disease severity was determined based on length of stay, PICU admission, and Remdesivir receipt. A χ2 analysis and a Cochran-Mantel-Haenszel test were used to analyze relationships between presumed variant type with admission reason, disease severity, and age. RESULTS: There were 492 patients included with more admissions during the omicron variant predominant time frame (n = 307). More patients were admitted "for COVID" during the delta variant predominant time frame compared with the omicron variant predominant time frame (P < .001) with interrater reliability testing indicating substantial agreement between reviewers. PICU admissions (P < .001), receipt of remdesivir (P < .001), and length of stay (P < .001) were greater during the delta variant predominant time frame. Hospitalizations "for COVID" were more common in patients aged <5 years during both the delta (odds ratio, 2.6; 95% confidence interval, 1.2-5.7) and omicron (odds ratio, 5.7; 95% confidence interval, 3.4-9.4) predominant time frames compared with older patients. CONCLUSIONS: There was a higher proportion of symptomatic COVID-19 hospitalizations with higher disease severity during the delta variant predominance, indicating greater disease severity during earlier periods of the pandemic despite lower hospitalization rates.

Association Between Corticosteroids and Outcomes in Children Hospitalized With Orbital Cellulitis.

OBJECTIVES: To examine the association between systemic corticosteroid use and outcomes for children hospitalized with orbital cellulitis at US children's hospitals. METHODS: We conducted a multicenter observational study using administrative data from the Pediatric Health Information System database from 2007 to 2019. Children between the ages of 2 months and 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification or 10th Revision, Clinical Modification discharge diagnostic codes of orbital cellulitis were included. The primary exposure was receipt of systemic corticosteroids on the day of hospital admission. The primary outcome was hospital length of stay, and secondary outcomes included surgical intervention, ICU admissions, revisits, and health care costs. We used generalized logit model with inverse probability weighting logistic regression to adjust for demographic factors and assess for differences in clinical outcomes reported. RESULTS: Of the 5832 patients hospitalized with orbital cellulitis, 330 (5.7%) were in the corticosteroid group and 5502 (94.3%) were in the noncorticosteroid group. Patients in the corticosteroid group were older, had more severe illness, and received broad spectrum antibiotics. In adjusted analyses, corticosteroid exposure was not associated with differences in length of hospital stay, need for surgical intervention, ICU admissions, emergency department revisits, 30-day hospital readmissions, or hospital costs. Restricting the analysis to only those patients who received broad spectrum antibiotics did not change the findings. CONCLUSIONS: Early use of systemic corticosteroids in hospitalized children with orbital cellulitis is not associated with improved clinical outcomes. Use of corticosteroids in hospitalized children with orbital cellulitis should be discouraged outside of clinical trials.

Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals.

Importance: The scope of low-value care in children's hospitals is poorly understood. Objective: To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants: This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures: Eligible condition-specific hospital encounters. Main Outcomes and Measures: The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results: There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance: This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses.

BACKGROUND AND OBJECTIVES: Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs. METHODS: We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or χ2 tests. Outcomes were modeled by using generalized linear mixed-effects models. RESULTS: Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22-0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92-1.02). CONCLUSIONS: Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs.

Pandemic-Related Shifts in New Patients Admitted to Children's Hospitals.

OBJECTIVES: During the coronavirus disease 2019 pandemic, professional organizations recommended preferential transfer of pediatric patients from general hospitals to children's hospitals. Patients previously receiving all care at other facilities would be new to children's hospitals. As a proxy for care consolidation, we sought to describe changes in new patient encounters at children's hospitals and test associations between local severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) incidences and new patient encounters. METHODS: This retrospective cohort study included patients aged 6 months to 18 years admitted to children's hospitals from March 15, 2019, to June 30, 2019 (control) and 2020 (pandemic period). Primary outcome was odds ratio of being a new versus established patient by study period. Generalized linear models estimated odds of being a new patient with adjustment for diagnosis. Analyses were also stratified by local SARS-CoV-2 transmission. RESULTS: There were 205 283 encounters (45.3% new patients). New patients were more common in the pandemic period than in the control (46.4 vs 44.7%, OR 1.07, 95% confidence interval [CI]: 1.05 to 1.09). After adjusting for diagnosis, pandemic new patients were no more common than control new patients (adjusted odds ratio 1.00, 95% CI: 0.98 to 1.02). Compared with hospitals experiencing low local SARS-CoV-2 transmission, admission encounters at both medium and high transmission hospitals were more likely to be new (adjusted odds ratio 1.08, 95% CI: 1.03 to 1.14 and 1.09, 95% CI: 1.03 to 1.15, respectively). CONCLUSIONS: During the early coronavirus disease 2019 pandemic, proportional increases in new patients to children's hospitals appeared to be due to changes in diagnoses but were also associated with local SARS-CoV-2 transmission. Pediatric care consolidation may have occurred; how this may have impacted outcomes for hospitalized children is unclear.

Risk of Serious Bacterial Infections in Young Febrile Infants With COVID-19.

OBJECTIVES: The purposes of this study were to describe the clinical characteristics of febrile infants younger than 90 days with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, to investigate the prevalence of serious bacterial infections (SBIs) in these infants, and to compare the risk of SBI in SARS-CoV-2-positive febrile infants with sex- and age-matched SARS-CoV- 2-negative febrile infants. METHODS: This was a retrospective cohort study conducted from March to November 2020 in a tertiary children's hospital. Patients were identified by International Classification of Diseases, 10th Revision codes and included if age was younger than 90 days, a SARS-CoV-2 test was performed, and at least 1 bacterial culture was collected. Positive cases of SARS-CoV-2 were age- and sex-matched to negative controls for analysis. Serious bacterial infection was defined as a urinary tract infection, bacterial enteritis, bacteremia, and/or bacterial meningitis. RESULTS: Fifty-three SARS-CoV-2-positive infants were identified with a higher rate of respiratory symptoms and lower white blood cell and C-reactive protein values than their SARS-CoV-2 matched controls. The rate of SBI in the SARS-CoV-2-positive infants was 8% compared with 34% in the controls; the most common infections were urinary tract infections (6% vs 23%). There were no cases of bacteremia or bacterial meningitis in the COVID-19 (coronavirus disease 2019) infants and 2 (4%) cases of bacteremia in the controls. The relative risk of any SBI between the 2 groups was 0.22 (95% confidence interval, 0.1-0.6; P ≤ 0.001). CONCLUSIONS: These results suggest that febrile infants younger than 90 days with COVID-19 have lower rates of SBI than their matched SARS-CoV-2-negative controls. These data are consistent with previous studies describing lower risks of SBI in febrile infants with concomitant viral respiratory tract infections.